How to Place and Secure an IO in a Peds Patient

Rebecca Engelman, a critical care paramedic and soon to be PA, sent the great tips below on how to secure an IO in a peds patient. She should know because on the equipment securing hierarchy, methods that work in the filed are tops. It goes: things that work in the OR to things that work in the ICU to things that work in the ED and ends with things that work in the eight floor walk-up apartment building or a transport chopper.

How to Place an IO

I’m a critical care paramedic and up until very recently I spend 95% of my time working in pediatric critical care transport.
Tibial IO in small peds (<10kg) can be tricky if you don’t do a lot of them. When everyone learned to insert EZIOs in adults, they were probably taught to drill until they felt a ‘pop’, then stop…then promptly forgot this direction and drilled until the hub of the catheter was resting on tissue. In adults, this usually doesn’t lead to problems due to the size of the medullary space. In small pediatric patients however, sinking the IO to the hub will result in the needle passing THROUGH the tibia. If this is not recognized upon insertion or upon fluid administration it can lead to the complications mentioned by others above.

Everything that I’m about to say is purely my opinion based on my experiences:
– Let someone who knows what they are doing put the EZIO in. We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill. (Some of our attendings didn’t even really belong on that list, that was just a politics thing.) We rarely had any issues after that. The point is, just like airway, if you don’t do it a lot in small kids, you probably aren’t going to be great at it.
– If you don’t put (not so) EZ-IOs into small kids a lot, consider using a manual IO. I personally think they are a lot harder to screw up. When I wasn’t working primarily in peds, I would use EZ-IO for adults and manual IOs for small kids (<10kg). I really like the Jamshidis because they have an adjustable flange so you can set the maximum depth.
– Once you get the IO in, flush vigouorously, look for an signs of infiltration, then SECURE THE HECK OUT OF IT. Any movement of the catheter increases the risk of infiltration. Be vigilant about checking for infiltration and checking distal perfusion.
– As Minh suggested, an IO is only a temporary solution. As soon as the patient is stable enough or has enough intravascular volume get a peripheral or central line in them as their status warrants.
– Some people have suggested that the proximal humerus might be a prefered site both for flow rates and patient comfort. I have no experience with this, but I wonder if, in peds, it might lead to a lower infiltration rate due to the larger medullary space.

How to Secure an IO

Here’s a link to some pictures I took this morning…http://db.tt/WnzgZkFY
If you are using a Jamshidi or another kind of IO catheter with a flange that rests on the skin, you can start with a couple pieces of tape over the flange.
If you don’t have a flange, take a piece of tape about 4-5? long and split it lengthwise about halfway down. Place the unsplit part on the skin and wrap the split ends around the hub of the IO catheter. I do this three times, spaced equally around the hub. (In case it isn’t clear, the coffee cup in the pictures represents the patient’s leg and the sharpie is the IO catheter hub.)
If you want to use tegaderm, now would be the time to apply it.
The next step is to build up a bukly dressing around the hub of the IO catheter and distal end of the IV tubing. I use roller gauze/king but anything would work. (This is represented by Epi-pen trainers in the pictures.) Tape all of this down. If you can still see the hub, you haven’t used enough bulky dressing.
The next step might be the most important for keeping the IO in place over the next few hours. Tape down, TO THE PATIENT, the next 8-12? of IV tubing. Make sure all stopcocks and ports are accessible, but also make sure that there can be ABSOLOUTLEY NO tension put on the line.

Vidacare also makes a stabilizer for EZ-IO catheters. They look nice, but I don’t have any experience with these as they are a bit pricy. I would guess that they would need a bit of stabilization in addition to this device and they definitely need the IV tubing secured.http://www.vidacare.com/EZ-IO/Products-Accessories.aspx (scroll down)

I hope this helps and I would love to hear if anyone has any other tips or tricks.

Rebecca
NREMT-P CCP-C

‘ Click for Full Size Image

These comments were added

Minh Le Cong:

Rebecca, awesome photos thankyou and love your tips on IO care.
One other tip from one of my colleagues. If small kid and worried you might insert IO straight through tibia, consider the greater trochanter of the femur. Biggest bone in body, easier target and reasonable cavity with less chance of going through other side with current generation of manual and semiautomatic IO devices.
He had to do this on a kid with meningococcal sepsis last month after multiple failed tibial and humeral IO attempts. Still wakes up in a cold sweat about that case.

Don Diakow:

Rebecca…….have used the Vidacare product numerous times and it works great. Like a large OP site with a hard plastic cover for the IO hub. The IV loop threads right over the stabilizer and with a few strips of tape can also be secured to the patient.

Comments

Scott,
Great post, but one issue is this statement “We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill.”

Just because residents may not be initially as adept at placing IOs, it doesn’t mean they shouldn’t be placing them. Like any procedure, if not done as a resident, that skillset won’t be there as an attending–when he/she is expected to be the final authority and definitive proceduralist.

Keep in mind that that particular critical care transport medic at one time was a novice in this procedure and may have had one or two failures.

I hear you. It is one of the toughest issues we as EM Academic Attendings have to cope with. How much training-on-the-patient is actually fair or right. For some things like ultrasound, there are now worries. For a pediatric IO, where no matter how well I describe the technique, it comes down to muscle memory–it is a near-impossible-to-solve problem. Good task trainers are the answer, but I’ve found very few procedures where they exist.

I understand your point. I think that the appropriate time and place for a green resident to “train on the patient,” as Scott put it, NOT at a outlying facility or in a helicopter. We simply do not have the hands or the resources.
In a trauma room or ICU supervised by an attending? That’s not my area, I won’t step on toes.

its a bit off topic but Jeff raises a good point. Medicine has always been an apprentice model of training and mastery. You cant simulate everything . Bruce Lee once said, you can try to teach swimming on dry land as much as you want, but nothing beats getting into the water!
Patient safety and quality care issues challenge us , responsible for training the next generation, as Scott says. Personally I take the view point that teaching and supervising someone to perform a life saving skill is a favourable balance of the patient safety vs training needs equation…in general but its a case by case anaylsis. Our teachers did this for us. that is the tradition. that is the discipline.

To help protect my IOs (even in adults) I place a roll of tape over the top of it so the roll lies flat to the skin. I then secure it with long strips of tape the te skin. That way the tape takes the knocks rather than the IO.

Thanks, Rebecca, for these excellent tips. Your comment about some folks suggesting proximal humerus is the preferred site is right on target. I’m one of those folks. Because of the lower intramedullary pressure there, you achieve simultaneously a 5x greater flow rate (vs prox tibia) AND less patient discomfort. Your target is much bigger, so despite more overlying soft tissue, I think with training that proper placement is actually easier at the humeral site. If you’re running a code (and you believe that epi works), humerally administered epi will get to the heart in about 0.5 seconds, just as if it had been given through subclavian or IJ central line. The only downside of the humeral site is that if you let the patient (or the CT tech) range the patient’s shoulder, it has a high rate of becoming displaced.

Rock on! It’s a great conference. Hope to see you in Austin, April 8-10, 2013, for CCTMC 2013. Call for speakers is ongoing now and due August 1, 2012; go to ampa.org for more info. And give that proximal humeral site a try next time you’ve got a patient needing an IO.

Here are my two bits on the whole IO experience. My background is in Prehospital medicine and ER as a nurse in a level one Adult and Peds Trauma center. The errors that I have seen in practice come back to lack of quality education prior to deployment of a new device. Also, needle choice and site choice is key. Not all peds pts get the 15mm needle most get the 25 mm needle.
Pushing the needle through the skin until you hit bone and then looking for a black line is a must. If you see a black line then give gentle pressure and let the driver do all of the work. Like previously mentioned, stop when you feel a pop or lack of resistance, in young children there might not be a big sensation of either. Hard flush with a 10cc fluid bolus to open up the medullary space to facilitate fluid delivery.
It is key to remember that children less than 1 year of age have very small tibias and if we fail to stabilize the IO with an appropriate dressing we will have failure due to the fluid pushing back on the needle (non-expanding closed space principle) and lose our placement. It is true that Vidacare makes a stabilization dressing that is approx. $4 and is well worth it.
An alternative site that we use in the <1 yr old population is the distal femur. This site has been around for a long time and gives us a larger area to hit. Keeping in mind that during most of these cases the patient has no adrenaline and we have too much.
In my opinion the humeral head is the preferred site for any adult. I have used it many times and have been able to infuse a Liter of NS in < 10 min. The beauty of it is since it dumps into the subclavian vein we can power inject into it for CT angios. This was well documented at Henry Ford in Michigan. The caveat is you cannot inject with the extension tubing on since the pressure will shred the tubing, but from my experience this is true with any extension tubing. If you put a saline lock cap on the end of the IO you can get around it.
Scott, I would just like to say thank you for the best education I have received in years. It is always a pleasure to listen to your podcasts. Thanks for doing this.
Hope this helps.
Kevin Guenard RN, CEN, CPEN, NREMT-P

So, to weigh in on this as a lowly resident and EMCrit fan since MSIII:
I can see how folks would prefer not to let residents put in lines, IOs, etc. It creates a potential problem for care of the individual patient – but saves our future patients a great deal of suffering. Everyone has a first.

I’ve noticed a truly distressing tendency for non-military-trained PAs to bar residents from procedures, and I understand that some folks are very results-oriented. As medical professionals, though, shouldn’t we work together to pool our knowledge rather than to create silos of care? This may just be my experience with our local culture.

Residents are incredibly aware of the problems of medical training – that we might cause problems for our firsts. It galls us. We read, and simulate, and try our hardest.

But the truest way to learn is by BEING in the situation.

The Hippocratic oath puts first a recommitment to passing on the craft, even before “do no harm”. Creating “no residents” rules is a flawed approach.

thanks for commenting, I agree with all you said above. For most procedures it is not a problem (chest tubes, etc.). It really comes down to vascular access procedures b/c no matter how much you talk your learner through it, it really comes down to needle feel and control. I think residents should have to practice with a vessel trainer and an ultrasound probe with a wire to pass 20 or thirty times (which you can do in 1 session). This would give me a resident that is very ready to do a central line on their 1st real patient without any problem.

I understand your point. The “no residents” rule is ONLY on transports and at outlying facilities. As I said above, what happens in the trauma room is between you and your attending.
There are several reasons this rule came about:
1. We have a small team and everyone has their defined roles. The resident needs to be getting a FULL report from the physician that was caring for the patient and reviewing labs/imaging/etc. The critical care paramedic(s) (with the help of the sending facility RNs) is then working to stabilize and package the patient for transport. If the resident gets too busy “playing paramedic” things get lost in the report and patient care suffers.
2. Critical care transport medicine is about getting to the patient, stabilizing them (as much as possible), then getting them to definitive treatment. It is really not a teaching environment. If I ran the zoo, this would be explicitly spelled out in our policies and procedures. At my (former) facility our residents simply did not have enough experience for this environment. On one hand it is great for the residents to be exposed to our cases and to pick up as much as they can, but on the other hand, sometimes we (the critical care paramedics) had to do a lot of hand holding, which brings me to my last point.
3. Paramedics are physician extenders. We practice under the license of a physician. I am more than happy to teach residents procedures, but when we are put in the position of “supervising” them in the field it can lead to some VERY sticky ethical, legal, logistical, and interpersonal situations.

Kevin Guenard’s post mentions something of incredible importance that deserves repeating – in *many* pediatric patients, the pink EZ-IO needle (labeled for 3-39 kg) is not long enough to penetrate flubber and enter the intramedullary cavity. We have had several infants in whom the pink needle wasn’t long enough, but older children in whom it is. Opening the needle set to find out the device isn’t of appropriate length for a given patient is wasteful – I’m at a point that I really don’t see the point in carrying the 15 mm needle set. Kevin I wonder what your thoughts are on this?

We have seen a few EZ-IO cannulae put through the tibia in kids. I think the key here is not avoiding using the driver, but rather, not pushing – simple advance the needle to the bone, trigger the driver, and let it do the work.

I’ve tried several different ways of securing the IO cannulas and I actually like that the EZ-IO does not have an adjustable flange. I usually take a big central line Tegaderm and put it straight down over everything and “tent” up the side where the extension set comes out from under the Tegaderm. Whatever way an IO is secured, please (please) make sure the site is readily visible with having to move dressings or bandages. Securing it “like an impaled object” prevents this.

Lastly, by the time anyone gets to the point of functioning as a member of a critical care transport team, they ought to have had a significant volume of training and initial competency validation. In the most frenetic of resuscitations, we can still find time to supervise procedure performance, and teach. I’ve had paramedic students, orienting flight nurses and paramedics, and even a PGY I pediatric resident (in August no less) place IO cannulae in emergencies. I don’t understand the circumstances at play in the CCT system described, but in my role, I want the novice to perform the procedure under supervision. They may never again have the opportunity to do it at the bedside and with the support of someone more experienced.

In reply to your question about the need to carry 15mm needles, I can say this. Our hospital/ems division oversees 40 ems/fire agencies, our advice to them is not to buy the 15mm needle and focus on the 25 and 45mm needles instead. We found agencies were waisting a lot of 15mm needles and as mentioned before most kids get a 25mm needle.

As far as teaching new medics/nurses/docs how to put in an IO, it can be tricky. Most importantly placing an IO in a preemie can be the most challenging. I recommend and have used a raw egg. It teaches the person placing the IO not to push and allow the driver to do all the work. If you do it correctly, you can get over 300 insertions into an egg prior to it breaking. If they do it wrong they can have breakfast.

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